Elimination of cervical cancer: ensuring equity
Authors: Deborah Bateson, Yin Ling Woo, Jayashri Kulkarni
Journal: The Lancet Public Health (2023)

In 2020, the Director General of WHO, Tedros Adhanom Ghebreyesus, launched a global strategy for the elimination of cervical cancer as a public health problem. Elimination (fewer than four new cases per 100 000 women per year) is now imaginable, and countries are urged to implement initiatives to achieve the 90%–70%–90% targets for 2030 across the three pillars of human papillomavirus (HPV) vaccination for girls, screening, and the treatment of cervical precancers and invasive cancers.1WHOGlobal strategy towards eliminating cervical cancer as a public health problem.https://www.who.int/publications/i/item/9789240014107Date: 2020Date accessed: March 6, 2023Google Scholar However, as shown by Kejia Hu and colleagues,2Hu K Wang J Sparén P et al.Invasive cervical cancer, precancerous lesions, and cervical screening participation among women with mental illness in Sweden: a population-based observational study.Lancet Public Health. 2023; 8: e266-e275Summary Full Text Full Text PDF Scopus (3) Google Scholar in this issue of The Lancet Public Health, a substantial proportion of women with mental illness are left behind with regard to cervical cancer prevention. Poor mental health is increasing globally affecting more than one billion people worldwide, and impacting substantially on health disparities.3GBD 2019 Mental Disorders CollaboratorsGlobal, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet Psychiatry. 2022; 9: 137-150Summary Full Text Full Text PDF PubMed Scopus (690) Google Scholar People with severe mental illness die prematurely due to preventable physical conditions and poor access to health interventions and treatment.4Momen NC Plana-Ripoll O Agerbo E et al.Mortality associated with mental disorders and comorbid general medical conditions.JAMA Psychiatry. 2022; 79: 444-453Crossref PubMed Scopus (17) Google Scholar These disparities can be hidden due to a scarcity of reliable data. Now Hu and colleagues2Hu K Wang J Sparén P et al.Invasive cervical cancer, precancerous lesions, and cervical screening participation among women with mental illness in Sweden: a population-based observational study.Lancet Public Health. 2023; 8: e266-e275Summary Full Text Full Text PDF Scopus (3) Google Scholar have powerfully documented how women with severe psychiatric or neurodevelopmental disorders are missing out on cervical screening and are twice as likely to be diagnosed with invasive cervical cancer. Using Sweden's comprehensive national registries, Hu and colleagues2Hu K Wang J Sparén P et al.Invasive cervical cancer, precancerous lesions, and cervical screening participation among women with mental illness in Sweden: a population-based observational study.Lancet Public Health. 2023; 8: e266-e275Summary Full Text Full Text PDF Scopus (3) Google Scholar combined three register-based studies of over 4 million women with and without mental illness or neurodevelopmental disorders between 1973 and 2018 to compare screening participation, detection of high-grade precancerous cervical lesions (cervical intraepithelial neoplasia [CIN2+]), and diagnosis of invasive cervical cancer across groups. The registry data allowed them to delineate specific Diagnostic and Statistical Manual of Mental Disorders (DSM) and then categorise these into severe illness (defined as having specialist diagnosis) or mild illness (defined as having had psychotropic medications prescribed in primary care without a specialist diagnosis). This categorisation has limitations as some commonly prescribed medications can be used for other conditions, and women whose mental illness is neither diagnosed by a specialist nor leads to the prescription of medications, will be missed. Other limitations are well described in the paper including incomplete information or missing information on other risk factors for HPV acquisition and persistence such as cigarette smoking and use of hormonal contraception.5Appleby P Beral V Berrington de González A et al.Carcinoma of the cervix and tobacco smoking: collaborative reanalysis of individual data on 13,541 women with carcinoma of the cervix and 23,017 women without carcinoma of the cervix from 23 epidemiological studies.Int J Cancer. 2006; 118: 1481-1495Crossref PubMed Scopus (337) Google Scholar, 6International Collaboration of Epidemiological Studies of Cervical CancerCervical cancer and hormonal contraceptives: collaborative reanalysis of individual data for 16 573 women with cervical cancer and 35 509 women without cervical cancer from 24 epidemiological studies.Lancet. 2007; 370: 1609-1621Summary Full Text Full Text PDF PubMed Scopus (384) Google Scholar However, this paper2Hu K Wang J Sparén P et al.Invasive cervical cancer, precancerous lesions, and cervical screening participation among women with mental illness in Sweden: a population-based observational study.Lancet Public Health. 2023; 8: e266-e275Summary Full Text Full Text PDF Scopus (3) Google Scholar has an important role in supporting global policy and practice changes to ensure elimination of cervical cancer is achieved equitably. Notably, it found women with severe mental illness had lower screening participation and were more likely to be diagnosed with invasive cancer than the general population. Screening participation was lowest in women with intellectual disability and autism, whereas women with substance abuse had a higher likelihood of invasive cancer. By contrast, individuals with mild illness were slightly more likely to be both screened and have high-grade cervical abnormalities detected but less likely to have invasive cancer than the general population, supporting the premise that greater screening access results in a higher chance of precancer treatment, thereby preventing invasive cancer. It is highly probable that women with mental illness are at increased risk of HPV-associated pathology due to barriers to screening and precancer treatment. Compared with the general population, they are more likely to have experienced child sexual abuse7Hailes HP Yu R Danese A Fazel S Long-term outcomes of childhood sexual abuse: an umbrella review.Lancet Psychiatry. 2019; 6: 830-839Summary Full Text Full Text PDF PubMed Scopus (263) Google Scholar or sexual violence as adults8Khalifeh H Moran P Borschmann R et al.Domestic and sexual violence against patients with severe mental illness.Psychol Med. 2015; 45: 875-886Crossref PubMed Scopus (124) Google Scholar. For women with intellectual disabilities, withholding of sexual health education, and de-prioritisation of screening due to competing health demands and misassumptions around consensual sexual activity by families and carers present additional barriers.9Chan DNS Law BMH Au DWH So WKW Fan N A systematic review of the barriers and facilitators influencing the cancer screening behaviour among people with intellectual disabilities.Cancer Epidemiol. 2022; 76102084Crossref Scopus (6) Google Scholar, 10Carter A Strnadová I Watfern C et al.The sexual and reproductive health and rights of young people with intellectual disability: a scoping review.Sex Res Soc Policy. 2022; 19: 372-390Crossref Scopus (13) Google Scholar Hu and colleagues' study2Hu K Wang J Sparén P et al.Invasive cervical cancer, precancerous lesions, and cervical screening participation among women with mental illness in Sweden: a population-based observational study.Lancet Public Health. 2023; 8: e266-e275Summary Full Text Full Text PDF Scopus (3) Google Scholar provides the crucial evidence to support an equitable approach to cervical cancer prevention through tailored accessible screening and treatment services staffed by skilled health professionals. With the introduction of self-sampling for HPV testing, many common barriers such as accessing a health-care facility, the need for speculum examinations, and frequent screening schedules can be removed. Women can now undertake self-screening tests in their own homes,11Tatara T Wnuk K Miazga W et al.The influence of vaginal hpv self-sampling on the efficacy of populational screening for cervical cancer-an umbrella review.Cancers. 2022; 145913Crossref Scopus (3) Google Scholar and as few as twice in their lifetime.1WHOGlobal strategy towards eliminating cervical cancer as a public health problem.https://www.who.int/publications/i/item/9789240014107Date: 2020Date accessed: March 6, 2023Google Scholar Although progress has been made in some countries, people with mental illness continue to experience stigma and discrimination. The paucity of political will and funding for tailored services for this group must be challenged. Future research and policy and practice efforts must also focus on other under-screened groups including those with physical disabilities, justice-involved women, migrants and refugees, Indigenous women, and LGBTIQ communities, ensuring these efforts are co-designed and community led. Only by increasing screening and treatment of cervical precancers for all populations, and ensuring equity in HPV vaccination, will progress be made along a path to elimination that leaves no one behind. DB has received equipment supplies from Cephied and funding support from the Minderoo Foundation, outside of the submitted comment. All other authors declare no competing interests. Invasive cervical cancer, precancerous lesions, and cervical screening participation among women with mental illness in Sweden: a population-based observational studyWomen with severe mental illness participate less in screening and experience a higher risk of cervical neoplasia. Refined approaches are needed to better target these women in the elimination agenda of cervical cancer. Full-Text PDF Open Access